Disulfiram (Antabuse)

Is taken daily, 250 mg/d after initial loading with 500 mg/d

Requires more informed consent and patient education, because if alcohol is ingested or absorbed, the patient may have violent nausea and vomiting

It is an aldehyde dehydrogenase inhibitor

It is aversive conditioning and a deterrent approach

Patient must clearly be sober prior to starting

This drug is harder to start in practice as it is time-consuming to educate the patient

Often when patients refuse to go to a rehabilitation facility for 28 days, they can be offered daily disulfiram instead, where they are ideally observed taking it by a sober support person or in the office itself

Both approaches theoretically can separate a person from ongoing alcohol use

The rehabilitation facility has physical walls

Disulfiram has mental walls due to the fear of vomiting

Naltrexone (ReVia)

Is taken 50 mg/d after use of a titration protocol

It is an opioid antagonist

Theoretically, it dampens the positive reward feelings from binge alcohol drinking and decreases the likelihood of future use after being sober as it separates the stimulus–response nature of alcohol ingestion and feeling good afterward

Acamprosate (Campral)

Is taken 666 mg three times a day

It is a glutamate metabotropic receptor antagonist

Theoretically, it dampens glutamate excitotoxicity when the influence of GABA-A PAM is withdrawn when alcohol sobriety occurs

• – GABA activity decreases and there is theoretically now unopposed glutamate hyperactivity

This may reduce alcohol cravings and aid in sobriety maintenance

For all agents, it is ideal if the patient achieves at least a few days of being sober prior to drug initiation

Posttest self-assessment question and answer

Which of the following are most accurate about gabapentin and its ability to treat psychiatric symptoms?

A. It alleviates mania

B. It alleviates panic attacks

C. It alleviates obsessive compulsive symptoms

D. It reduces alcohol consumption

E. A and C

F. B and D

G. All of the above

Answer: F

A review of off-label literature and review articles suggests a moderately stringent evidence base supporting the use of gabapentin to diminish panic, social anxiety, and alcohol consumption. There is much less evidence, and even negative outcomes, for treating mania. There is clear supportive evidence for its use in treating epilepsy and neuropathic pain disorders.

References

1.Myrick H, Anton R, Voronin K, Wang W, Henderson S. A double-blind evaluation of gabapentin on alcohol effects and drinking in a clinical laboratory paradigm. Alcohol Clin Exp Res 2007; 31:221–7.

2.Furieri FA, Nakamura-Palacios EM. Gabapentin reduces alcohol consumption and craving: a randomized, double-blind, placebo-controlled trial. J Clin Psychiatry 2007; 68:1691–700.

3.Bonnet U, Banger M, Leweke FM, et al. Treatment of acute alcohol withdrawal with gabapentin: results from a controlled two-center trial. J Clin Psychopharmacol 2003; 23:514–9.

4.Letterman L, Markowitz JS. Gabapentin: a review of published experience in the treatment of bipolar disorder and other psychiatric conditions. Pharmacotherapy 1999; 19:565–72.

5.Pande AC, Pollack MH, Crockatt J, et al. Placebo-controlled study of gabapentin treatment of panic disorder. J Clin Psychopharmacol 2000; 20:467–71.

6.Pande AC, Davidson JR, Jefferson JW, et al. Treatment of social phobia with gabapentin: a placebo-controlled study.J Clin Psychopharmacol 1999; 19:341–8.

7.Mula M, Pini S, Cassano GB. The role of anticonvulsant drugs in anxiety disorders: a critical review of the evidence. J of Clin Psychopharmacol 2007; 27:263–72.

8.Taylor CP, Gee NS, Su TZ, et al. A summary of mechanistic hypotheses of gabapentin pharmacology. Epilepsy Res 1998; 29:231–46.

9.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th edn. Washington, DC: American Psychiatric Association Press, 2013.

10.Stahl SM. Stahl’s Essential Psychopharmacology, 4th edn. New York, NY: Cambridge University Press, 2013.

11.Stahl SM. Stahl’s Essential Psychopharmacology: The Prescriber’s Guide, 5th edn. New York, NY: Cambridge University Press, 2014.

Patient file

The Case:

Oops…he fell off the curve

The Question:

What to do when patients lose too much weight

The Dilemma:

In the era of weight-gain side-effect notoriety, the stimulants may cause equally problematic loss in weight and stature

Pretest self-assessment question (answer at the end of the case)

Which of the following do not appear to have marked weight-loss adverse effects when treating children with ADHD?

A. Guanfacine–ER (Intuniv)

B. Clonidine-ER (Kapvay)

C. Atomoxetine (Strattera)

D. Lisdexamfetamine (Vyvanse)

E. A and B

F. A, B, and C

G. All of the above